As a valuable partner of CIBC’s, it is vital we have the most accurate and up to date information in our records as it relates to your groups employee benefit offerings. As we prepare for your annual renewal process, please complete the following questionnaire. This will help ensure we are providing you with the most accurate information during our annual analysis of your employee benefits.

Group Name *

Tax ID #

Address (City, State, Zip) *

Primary Contact *

Job Title *

Email Address *

Contact 2

Job Title

Contact 2 Email

Contact 3

Job Title

Contact 3 Email

Total # of Employees (FT, PT, etc.) *

Total # of Eligible Employees (eligible to be on the plan) *

Prior Calendar Year ATNE *

*To calculate ATNE, use the prior calendar year. Take the total employee count (full time, part time, etc) for each month, add those numbers together and divide by 12.

Current Calendar Year ATNE

How much do you contribute towards medical employee and dependent premiums?

Please indicate if amounts are based on a % of a premium or a fixed $ amount.

How much do you contribute towards dental employee and dependent premiums?

If applicable

How much do you contribute towards vision employee and dependent premiums?

If applicable

How much do you contribute towards group life/ADD employee and dependent premiums?

If applicable

How much do you contribute towards STD employee and dependent premiums?

If applicable

How much do you contribute towards LTD employee and dependent premiums?

If applicable

How much does your lowest paid employee earn (optional)?

This information is used by CIBC to help Applicable Large Employers (50+, as defined by the Affordable Care Act) calculate if their benefits meet affordability thresholds.

How many hours per week must an employee work to be considered eligible for coverage?

Does this apply to all benefits you offer?

Yes

No

If no, please provide details

When is a new hire eligible for coverage?

Is this the same for all benefits you offer

Yes

No

If no, please provide details

When an employee terminates employment with your company, when do their benefits terminate?

Is this the same for all benefits offered?

Yes

No

If no, please provide details

Additional Comments

If you have any questions on the information requested in this document, please contact your CIBC Account Manager or call Amanda Mast at
217-840-1460 or email amast@cibcinc.com